Discrete Choice Experiment to Estimate Breast Cancer Patients’ Preferences and Willingness to Pay for Prophylactic Granulocyte Colony-Stimulating Factors

ObjectivesRising out-of-pocket costs for cancer patients have increased shared decision making. Clinical guidelines recommend prophylactic granulocyte colony-stimulating factor (G-CSF) for patients receiving chemotherapy with a 20% or greater risk of febrile neutropenia. A discrete choice experiment was conducted to explore breast cancer patients’ preferences and willingness to pay (WTP) for prophylactic G-CSF to decrease the risk of chemotherapy-induced febrile neutropenia.MethodsAn online discrete choice experiment questionnaire survey of a national US convenience sample of self-reported breast cancer patients with prior chemotherapy treatment was conducted. Sixteen paired G-CSF treatment scenarios, each with four attributes (risk of disruption to chemotherapy schedule due to low white blood cell counts, risk of developing an infection requiring hospitalization, frequency of administration, and total out-of-pocket cost) were presented with a follow-up “no treatment” option. Participant preferences and WTP out of pocket were estimated by logistic regression.ResultsParticipants (n = 296) preferred G-CSF regimens with lower out-of-pocket costs, lower risk of chemotherapy disruption, lower risk of infection, and greater convenience (one G-CSF injection per chemotherapy cycle). Participants’ WTP was $1076 out of pocket per cycle to reduce the risk (high to low) of disrupting their chemotherapy schedule, $884 per cycle to reduce the risk (24% [high] to 7% [low]) of infection, and $851 per cycle to decrease the number of G-CSF injections (11 to 1) per cycle.ConclusionsParticipants highly valued specific features of prophylactic G-CSF treatment including maintaining their chemotherapy schedule, lowering their risk of infection, and reducing the number of injections. Physicians should consider patient preferences to inform the best treatment choices for individual patients.     

Risk factors for progression to regular injection drug use among street-involved youth in a Canadian setting

Background

Street-involved youth are at high risk for experimenting with injection drug use; however, little attention has been given to identifying the factors that predict progression to on-going injecting.

Methods

Logistic regression was used to identify factors associated with progression to injecting weekly on a regular basis among a Canadian cohort of street-involved youth.

Results

Among our sample of 405 youth who had initiated injecting at baseline or during study observation, the median age was 22 years (interquartile range [IQR] = 21–24), and 72% (293) reported becoming a regular injector at some point after their first injection experience. Of these, the majority (n = 186, 63%) reported doing so within a month of initiating injection drug use. In multivariate analysis, the drug used at the first injection initiation event (opiates vs. cocaine vs. methamphetamine vs. other; all p > 0.05) was not associated with progression; however, younger age at first injection (adjusted odds ratio [AOR] = 1.13), a history of childhood physical abuse (AOR = 1.81), prior regular use of the drug first injected (AOR = 1.77), and having a sexual partner present at the first injection event (AOR = 2.65) independently predicted progression to regular injecting.

Conclusion

These data highlight how quickly youth progress to become regular injectors after experimentation. Findings indicate that addressing childhood trauma and interventions such as evidence-based youth focused addiction treatment that could prevent or delay regular non-injection drug use, may reduce progression to regular injection drug use among this population.     

Population pharmacokinetics of tanezumab in phase 3 clinical trials for osteoarthritis pain

AimsThe aims were to 1) develop the pharmacokinetics model to describe and predict observed tanezumab concentrations over time, 2) test possible covariate parameter relationships that could influence clearance and distribution and 3) assess the impact of fixed dosing vs. a dosing regimen adjusted by body weight.MethodsIndividual concentration–time data were determined from 1608 patients in four phase 3 studies conducted to assess efficacy and safety of intravenous tanezumab. Patients received two or three intravenous doses (2.5, 5 or 10 mg) every 8 weeks. Blood samples for assessment of tanezumab PK were collected at baseline, 1 h post‐dose and at weeks 4, 8, 16 and 24 (or early termination) in all studies. Blood samples were collected at week 32 in two studies. Plasma samples were analyzed using a sensitive, specific, validated enzyme‐linked immunosorbent assay.ResultsA two compartment model with parallel linear and non‐linear elimination processes adequately described the data. Population estimates for clearance (CL), central volume (V₁), peripheral volume (V₂), inter‐compartmental clearance, maximum elimination capacity (VM) and concentration at half‐maximum elimination capacity were 0.135 l day^–1, 2.71 l, 1.98 l, 0.371 l day^–1, 8.03 μg day^–1 and 27.7 ng ml^–1, respectively. Inter‐individual variability (IIV) was included on CL, V₁, V₂ and VM. A mixture model accounted for the distribution of residual error. While gender, dose and creatinine clearance were significant covariates, only body weight as a covariate of CL, V₁ and V₂ significantly reduced IIV.ConclusionsThe small increase in variability associated with fixed dosing is consistent with other monoclonal antibodies and does not change risk : benefit.     

Changing gender relations among young people: The global challenge for HIV/AIDS prevention

The worldwide epidemic of human immunodeficiency virus (HIV) has affected different populations in different countries. Yet, every country has recognized the particular vulnerability of its young people to possible infection. This vulnerability is commonly thought to relate in the main to young people's assumed universal interest in sexual experimentation.

Various studies have demonstrated not only both worrying levels of sexual risk-taking among some young people, but also significant care being taken by others in relation to HIV/AIDS risk. Young people are clearly not a singularity, but rather live their lives in varying social and cultural circumstances that have a bearing on their sexual activities and their ideas about sex. This paper reports on a comparative study of the social and contextual factors affecting young people's risk-related sexual behaviour in seven developing countries. The study was commissioned by the World Health Organization's former Global Programme on AIDS and overseen to completion by the Joint United Nations Programme on AIDS (UNAIDS). The paper outlines the study's cross-cultural design and qualitative methodology, and in particular reports its major findings on gender relations among young people. The findings argue strongly for a reconceptualization of young people's sexuality and for different kinds of research needed to obtain more subtle, detailed social and cultural data for use in designing educational interventions for young people in relation to HIV/AIDS.     

"New century,new challenges"

The recently published report ‘New Century, New Challenges’from the Heads of Departments of General Practice and PrimaryCare sets out a vision for the development of academic generalpractice in the UK.¹ It reviews the substantial challenges nowfacing the academic departments and shows clearly how more investmentis essential if general practice and primary care services topatients are to be improved under the Government’s NHSPlan.² In 2001, there were 31 academic departments of general practiceand primary care in the UK compared with 24 departments in 1986.In the period since 1986, the number of professors of generalpractice increased from 16 to 66, and the proportion of non-clinical     

Can health care quality indicators be transferred between countries?

Objective: To evaluate the transferability of primary care quality indicators by comparing indicators for common clinical problems developed using the same method in the UK and the USA.

Method: Quality indicators developed in the USA for a range of common conditions using the RAND-UCLA appropriateness method were applied to 19 common primary care conditions in the UK. The US indicators for the selected conditions were used as a starting point, but the literature reviews were updated and panels of UK primary care practitioners were convened to develop quality indicators applicable to British general practice.

Results: Of 174 indicators covering 18 conditions in the US set for which a direct comparison could be made, 98 (56.3%) had indicators in the UK set which were exactly or nearly equivalent. Some of the differences may have related to differences in the process of developing the indicators, but many appeared to relate to differences in clinical practice or norms of professional behaviour in the two countries. There was a small but non-significant relationship between the strength of evidence for an indicator and the probability of it appearing in both sets of indicators.

Conclusion: There are considerable benefits in using work from other settings in developing measures of quality of care. However, indicators cannot simply be transferred directly between countries without an intermediate process to allow for variation in professional culture or clinical practice.

     

Dietary patterns related to glycemic index and load and risk of premenopausal and postmenopausal breast cancer in the Western New York Exposure and Breast Cancer Study

BACKGROUND: Reduced rank regression (RRR) has been used to identify dietary patterns that predict variation in a selected risk factor and may be useful in describing dietary exposures associated with glycemic index (GI) and glycemic load (GL). OBJECTIVE: To estimate breast cancer risk, we compared the relative utility of RRR-derived dietary patterns predictive of GI and GL with those of simple GI and GL. DESIGN: RRR was used to identify dietary patterns predicting GI and GL from food-frequency data obtained in the Western New York Exposure and Breast Cancer Study (1166 cases, 2105 controls). Odds ratios (ORs) and 95% CIs were estimated with unconditional logistic regression, adjusted for energy and nondietary breast cancer risk factors. RESULTS: Sweets, refined grains, and salty snacks explained 34% of the variance in GI and 68% of the variance in GL. In general, breast cancer risks were not associated with GI, GL, or dietary pattern score. However, we observed a significant reduction in postmenopausal breast cancer risk with GI and GL pattern scores combined (OR: 0.68; 95% CI: 0.50, 0.93), especially in women with a body mass index (in kg/m(2)) >or=25 (OR: 0.64; 95% CI: 0.44, 0.93). Conversely, in premenopausal women, increased risks were associated with high GL pattern scores only for women with a body mass index >or=25 (OR: 2.21; 95% CI: 1.04, 4.69). CONCLUSIONS: Although RRR may be useful in studies of diet and disease, our results suggest that RRR dietary patterns based on GI and GL provide similar information regarding the association between breast cancer, GI, and GL.     

Reduction in hospitalwide incidence of infection or colonization with methicillin-resistant Staphylococcus aureus with use of antimicrobial hand-hygiene gel and statistical process control charts.

OBJECTIVE: To evaluate the impact of serial interventions on the incidence of methicillin-resistant Staphylococcus aureus (MRSA). DESIGN: Longitudinal observational study before and after interventions. SETTING: The Alfred Hospital is a 350-bed tertiary referral hospital with a 35-bed intensive care unit (ICU). INTERVENTIONS: A series of interventions including the introduction of an antimicrobial hand-hygiene gel to the intensive care unit and a hospitalwide MRSA surveillance feedback program that used statistical process control charts but not active surveillance cultures. METHODS: Serial interventions were introduced between January 2003 and May 2006. The incidence and rates of new patients colonized or infected with MRSA and episodes of MRSA bacteremia in the intensive care unit and hospitalwide were compared between the preintervention and intervention periods. Segmented regression analysis was used to calculate the percentage reduction in new patients with MRSA and in episodes of MRSA bacteremia hospitalwide in the intervention period. RESULTS: The rate of new patients with MRSA in the ICU was 6.7 cases per 100 patient admissions in the intervention period, compared with 9.3 cases per 100 patient admissions in the preintervention period (P=.047). The hospitalwide rate of new patients with MRSA was 1.7 cases per 100 patient admissions in the intervention period, compared with 3.0 cases per 100 patient admissions in the preintervention period (P<.001). By use of segmented regression analysis, the maximum and conservative estimates for percentage reduction in the rate of new patients with MRSA were 79.5% and 42.0%, respectively, and the maximum and conservative estimates for percentage reduction in the rate of episodes of MRSA bacteremia were 87.4% and 39.0%, respectively. CONCLUSION: A sustained reduction in the number of new patients with MRSA colonization or infection has been demonstrated using minimal resources and a limited number of interventions.